Auburn School District

Auburn School District

VERIFICATION OF RESIDENCY STATEMENT

In order to verify residency within the Auburn School District, ONE current document from the following list MUST be

provided. The document must be dated within the last thirty days showing parent/guardian name and address (P.O. Box

numbers are not acceptable as a residential address).

Escrow papers, mortgage book or statement, or homeowner's association fees statement

Lease Agreement and current rent receipt

Rental contract and current rent receipt

Letter on apartment complex or mobile home park letterhead, signed by the landlord, stating that

parent/guardian lives at the stated address

Gas bill

Electric bill

Water bill

Cable TV bill

Garbage bill

Phone bill for a land line at the stated address

Residence insurance statement

Verification of social services

Verification of living with

. Must complete and attach Co-Residency Form.

(Name)

If you are unable to provide any of the above items, please request a meeting with the school administrator to complete Residency Agreement. This Agreement will give you extra time to collect the needed documents.

A Residency Agreement is requested

Student's Name:

Parent/Guardian's Name:

Resident Address:

I declare that the above-named student resides at the address shown on one of the documents indicated above and attached to this enrollment packet. I will notify the school within two weeks of residency changes and agree to provide a new proof of residency and updated signed statement at that time. If I move outside of the school district boundaries, I understand an inter-district attendance release must be filed in order to request continued attendance for this student.

Falsification of any information or document required for residency verification, or the use of the address of another person without actually residing there, may result in revocation of student's enrollment in the Auburn School District (see Policy 3131).

Parent/Guardian Signature:

Date:

Auburn School District

CO-RESIDENCY FORM

This form is required for families who share a home with another individual or family member (e.g. rent a room in a house). A completed Residency Verification Form is also required.

This form accompanies the Residency Verification Form of the following student(s):

Please print student(s) name(s) (first and last)

The PARENT/GUARDIAN must present to the school: A completed Residency Verification Form A completed, notarized original of this form

The PRIMARY RESIDENT/OWNER of the shared home is required to complete this section and present a copy to the school, of the items below:

His or her driver's license, government issued ID, or passport with photo ID Two (2) bulleted items on the Establishing and Verifying Residency Checklist

I, (please print)

(primary resident/owner) declare that I am the primary

resident/owner of the address listed below and on the attached Residency Verification Form (RVF) and that the person(s)

claiming the address on the RVF reside(s) with me at least four (4) days per week. I further declare that the information

provided in the RVF including information provided by the parent(s)/guardian(s), is true and correct. I understand that

home visitation and/or residency verification is a part of a periodic process to confirm residency established by a Residency

Verification Form. I will submit the required pieces of evidence to verify my residency. I agree to notify the Auburn School

District if there is any change in the status of the residency of the persons listed on the RVF or myself.

I certify the foregoing information to be true and recognize that falsification or omission of information could result in modification of the school or program placement for this student including withdrawal from school. Address Number Street Unit # City/State ZIP code A Residency Agreement is attached.

Address

Number

Street

Unit #

City/State

ZIP code

Signature of Primary Resident/Owner (witnessed by notary)

Date

Section below to be completed by Notary Public: STATE OF WASHINGTON COUNTY OF On this day personally appeared before me ______________________________, to me known to be the individual(s) described in and who executed the within and foregoing instrument, and acknowledged that he/she/they signed the same as his/her/their free and voluntary act and deed, for the uses and purposes therein mentioned.

Given under my hand and seal of office this

day of

, 20 .

Printed Name: Notary Public residing at My Commission Expires:

INSTRUCTIONS: How to Obtain Immunization Records for School Entry

Starting August 1, 2020, medically verified immunization records are required for school entry. Medically verified records include either printing the Certificate of Immunization from MyIR or filling out a Certificate of Immunization Status form and attaching one of the required additional documents listed below.

Printing a Certificate of Immunization printed from MyIR is the first option for obtaining student immunization records:

Create a MyIR account

To obtain Washington State immunization information register under "Washington"

Follow the steps, complete the required information

Add your child's information then confirm and register

Download and print the Certificate of Immunization

OR

Another option is filling out the Certificate of Immunization Status (CIS) form and attaching: o A healthcare provider signature OR o Official lifetime immunization record with provider stamp or signature OR o Official Immigration immunization record OR o Immunization record printed from a healthcare provider, clinic, or hospital OR o Written immunization record with a provider stamp or signature

The above items also work for a prior to August 1 start date.

4-30-20

Dept. of Tech ? Data Services ? CIS Inst

Page 1 of 1

Certificate of Immunization Status (CIS)

Reviewed by:

Date:

Signed COE on File? Yes No

Please print. See back for instructions on how to fill out this form or get it printed from the Washington State Immunization Information System.

Child's Last Name:

First Name:

Middle Initial:

Birthdate (MM/DD/YYYY):

I give permission to my child's school/child care to add immunization information into the Conditional Status Only: I acknowledge that my child is entering school/child care in

Immunization Information System to help the school maintain my child's record.

conditional status. For my child to remain in school, I must provide required documentation

of immunization by established deadlines. See back for guidance on conditional status.

X

Parent/Guardian Signature

X

Date

Parent/Guardian Signature Required if Starting in Conditional Status Date

Required for School Required Child Care/Preschool

Date

Date

Date

Date

Date

Date

MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY

Required Vaccines for School or Child Care Entry

DTaP (Diphtheria, Tetanus, Pertussis)

Tdap (Tetanus, Diphtheria, Pertussis) (grade 7+)

DT or Td (Tetanus, Diphtheria)

Hepatitis B

Hib (Haemophilus influenzae type b)

IPV (Polio) (any combination of IPV/OPV)

OPV (Polio)

MMR (Measles, Mumps, Rubella)

PCV/PPSV (Pneumococcal)

Varicella (Chickenpox) History of disease verified by IIS

Recommended Vaccines (Not Required for School or Child Care Entry)

Flu (Influenza)

Hepatitis A

HPV (Human Papillomavirus)

MCV/MPSV (Meningococcal Disease types A, C, W, Y)

MenB (Meningococcal Disease type B)

Rotavirus

Documentation of Disease Immunity (Health care provider use only)

If the child named in this CIS has a history of varicella (chickenpox) disease or can show immunity by blood test (titer), it must be verified by a health care provider.

I certify that the child named on this CIS has: A verified history of varicella (chickenpox) disease. Laboratory evidence of immunity (titer) to disease(s) marked below.

Diphtheria Hepatitis A Hepatitis B

Hib

Measles Mumps

Rubella Tetanus Varicella

Polio (all 3 serotypes must show immunity)

Licensed Health Care Provider Signature Date Printed Name

I certify that the information provided on this form is correct and verifiable.

Health Care Provider or School Official Name: ______________________________ Signature: ______________________ Date:___________ If verified by school or child care staff the medical immunization records must be attached to this document.

Instructions for completing the Certificate of Immunization Status (CIS): Print the from the Immunization Information System (IIS) or fill it in by hand.

To print with the immunization information filled in: Ask if your health care provider's office enters immunizations into the WA Immunization Information System (Washington's statewide registry). If they do, ask them to print the CIS from the IIS and your child's immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at . If your provider doesn't use the IIS, email or call the Department of Health to get a copy of your child's CIS: waiisrecords@doh. or 1-866-397-0337.

To fill out the form by hand: 1. Print your child's name and birthdate, and sign your name where indicated on page one. 2. Write the date of each vaccine dose received in the date columns (as MM/DD/YY). If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guides below to record each vaccine correctly. For example, record Pediatix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. 3. If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements.

If your health care provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section. 4. If your child can show positive immunity by blood test (titer), have your health care provider check the boxes for the appropriate disease in the Documentation of Disease Immunity section, and sign and date the form. You must provide lab reports with this CIS. 5. Provide proof of medically verified records, following the guidelines below.

Acceptable Medical Records All vaccination records must be medically verified. Examples include:

A Certificate of Immunization Status (CIS) form printed with the vaccination dates from the Washington State Immunization Information System (IIS), MyIR, or another state's IIS. A completed hardcopy CIS with a health care provider validation signature. A completed hardcopy CIS with attached vaccination records printed from a health care provider's electronic health record with a health care provider signature or stamp. The school administrator,

nurse, or designee must verify the dates on the CIS have been accurately transcribed and provide a signature on the form.

Conditional Status Children can enter and stay in school or child care in conditional status if they are catching up on required vaccines for school or child care entry. (Vaccine series doses are spread out among minimum intervals, so some children may have to wait a period of time before finishing their vaccinations. This means they may enter school while waiting for their next required vaccine dose). To enter school or child care in conditional status, a child must have all the vaccine doses they are eligible to receive before starting school or child care.

Students in conditional status may remain in school while waiting for the minimum valid date of the next vaccine dose plus another 30 days time to turn in documentation of vaccination. If a student is catching up on multiple vaccines, conditional status continues in a similar manner until all of the required vaccines are complete.

If the 30-day conditional period expires and documentation has not been given to the school or child care, then the student must be excluded from further attendance, per RCW 28A.210.120. Valid documentation includes evidence of immunity to the disease in question, medical records showing vaccination, or a completed certificate of exemption (COE) form.

Reference guide for vaccine trade names in alphabetical order For updated list, visit ms/usvaccines.html

Trade Name Vaccine

Trade Name Vaccine

Trade Name Vaccine

Trade Name Vaccine

Trade Name Vaccine

ActHIB

Hib

Fluarix

Flu

Havrix

Hep A

Menveo

Meningococcal

Rotarix

Rotavirus (RV1)

Adacel

Tdap

Flucelvax

Flu

Hiberix

Hib

Pediarix

DTaP + Hep B + IPV RotaTeq

Rotavirus (PV5)

Afluria

Flu

FluLaval

Flu

HibTITER

Hib

PedvaxHIB

Hib

Tenivac

Td

Bexsero

MenB

FluMist

Flu

Ipol

IPV

Pentacel

DTaP + Hib +IPV Trumenba MenB

Boostrix

Tdap

Fluvirin

Flu

Infanrix

DTaP

Pneumovax

PPSV

Twinrix

Hep A + Hep B

Cervarix

2vHPV

Fluzone

Flu

Kinrix

DTaP + IPV

Prevnar

PCV

Vaqta

Hep A

Daptacel

DTaP

Gardasil

4vHPV

Menactra

MCV or MCV4

ProQuad

MMR + Varicella Varivax

Varicella

Engerix-B

Hep B

Gardasil 9

9vHPV

Menomune MPSV4

Recombivax HB Hep B

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711).

DOH 348-013 November 2019

Student Health History

Student Name (Last,First)

Birthdate: _______________Grade:________ Gender:_______

State law requires that students with life-threatening conditions such as anaphylaxis, severe asthma, diabetes or seizures have a care plan completed along with any required medication prior to the first day of school. Contact the school nurse as soon as possible to complete the proper forms.

Does your student have a LIFE-THREATENING health condition? Yes No

MEDICAL HISTORY (check all that apply)

Life-Threatening Conditions: (Care plan is REQUIRED)

EG Anaphylaxis (Epi-pen prescribed)

Allergic to EK Diabetes Type 1 NP Seizures ? Emergency medication required?

Type: RG Asthma ? Severe

Other Life-Threatening Condition:

Nervous System

NB NC NE NF NH NI NP NU

ADHD / ADD diagnosed by: Autism Spectrum Disorder Cerebral Palsy

Developmental Disability Migraines Headaches, Recurring

Seizure Disorder Current History Type: Traumatic Brain Injury

Congenital / Genetic AH Down Syndrome AJ Fetal Alcohol Spectrum Disorder

Other conditions, please describe:

Other Neurological Condition:

Transplant OD List organ:

Blood / Hematology

BA Anemia

BB Hemophilia

BC Sickle Cell

Disease

Trait

OJ History of Severe Nosebleeds

Other Blood Condition:

Cardiac / Heart CC Heart Birth Defect CD Heart Murmur

Other Cardiovascular Condition:

Allergy, Immune, Endocrine, Metabolic and Nutritional ED Allergy ? Food: EE Allergy ? Insect:

Allergy ? Other List: EL Diabetes Type 2

Other Endocrine, Immune, Nutritional or Metabolic:

Gastrointestinal, Dental and Oral GA Celiac GG Food Intolerance / Religious Preference

List: GL Lactose Intolerance

GF Encopresis GO Chronic Constipation GH Gastric Reflux GJ Inflammatory Bowel Disease GK Irritable Bowel Syndrome

Other Gastrointestinal, Liver, Dental, Oral Condition:

Musculoskeletal MC Juvenile Rheumatoid / Idiopathic Arthritis

Please list:

Cancer / Tumor Please list:

Mental or Behavioral Health PA Anxiety PC Depression PH Sleep Disorder

Other Mental or Behavioral Health Condition

Respiratory / Breathing RG Asthma ? Current RH Asthma ? Ever Diagnosed RA Asthma ? Exercised Induced RE Reactive Airway Disease

Other Respiratory Condition:

Skin SB

Eczema or Contact Dermatitis or Psoriasis Other Skin Condition:

Renal / Kidney Please list:

Ear / Hearing YA Chronic Ear Infections Currently Historically YB Hearing Impaired Hearing Aid/s Cochlear Implant

Other Ear Condition:

Eye / Vision YF Wears glasses / contacts YE Color Vision Deficit YD Visually Impaired

Other Eye Condition:

Other Health Concerns Please list:

No Known Health Concerns OC Please Initial:

v4-2020

(See reverse ? complete information on page 2)

Student Health History

Student Name (Last,First)

Birthdate: _______________Grade:________ Gender:_______

MEDICATIONS

Please report all medications that your student takes at home and/or at school.

Is medication needed at home?

No Yes Please list:

Is medication needed at school? No Yes Please list:

Complete REQUIRED paperwork for medication at school.

State law requires written permission from guardian and a health care provider before any medication (prescription and overthe-counter) may be taken at school. Forms are available from your school office or on our district website and must be completed annually.

Medical Devices / Equipment / Procedures Example: Gastrostomy tube, VP Shunt, Catheterization, Vagal Nerve Stimulator, or Other Please Describe:

Physical Activity or Mobility Issues / Assistive Equipment Example: wheelchair, braces, or Other

Please Describe:

To help us better understand your child, please complete the following: Health/Developmental History: Birth and Infancy: Birth Weight______ Was pregnancy Full Term? Yes No Duration of pregnancy_________________________________ At what age was your child: Toilet trained?___________________Walking?_______________________ Talking?________________________ Hospitalizations?______________________________________________________________________________________________________ Serious Injuries?_______________________________________________________________________________________________________ Specialist?____________________________________________________________________________________________________________ What other information would be helpful for us to know regarding your child? Please share. _________________________________________ _____________________________________________________________________________________________________________________

I understand that the information I provided will be shared with appropriate school staff who need to know in order to provide for the health and safety of my student. If parents/guardians or authorized emergency contacts cannot be reached at the time of a medical emergency, and if immediate care is urgent in the judgement of school authorities, I authorize and direct the school authorities to send the student to the hospital or doctor most easily accessible. I understand that I will assume full responsibility for the payment of any services rendered. I understand that Washington law requires that my student's immunizations are complete or conditional before starting school. I give permission to my child's school to add immunization information to the Immunization Information System to help the school maintain my child's school record.

Parent/Legal Guardian Signature: _______________________________________________

Date: _______________________

Parent/Guardian phone/cell________________________________________________________Work _________________________________

Emergency contact/relationship_____________________________________________________Phone_________________________________

Health Care Provider Name_________________________________________________________Phone_________________________________

For Office Use only: Complete Immunization Records Complete IIS #__________________ IIS Copy Provided___ Medically verifiable records provided_____ COE_____ or Conditional status________ Parent signed acknowledgment or Out of compliance______

v4-2020

Office of Superintendent of Public Instruction (OSPI) Home Language Survey

English/November 201

The Home Language Survey is given to all students enrolling in Washington schools.

Student Name:

Grade:

Date:

Parent/Guardian Name

Parent/Guardian Signature

Right to Translation and Interpretation Services Indicate your language preference so we can provide an interpreter or translated documents, free of charge, when you need them.

All parents have the right to information about their child's education in a language they understand.

1. In what language(s) would your family prefer to communicate with the school? __________________________________

Eligibility for Language Development Support Information about the student's language helps us identify students who qualify for support to develop the language skills necessary for success in school. Testing may be necessary to determine if language supports are needed.

2. What language did your child learn first? __________________________________

3. What language does your child use the most at home? __________________________________

4. What is the primary language used in the home, regardless of the language spoken by your child? __________________________________

5. Has your child received English language development support in a previous school? Yes___ No___ Don't Know___

Prior Education

Your responses about your child's birth country and previous education: Give us information about the

knowledge and skills your child is bringing to school. May enable the school district to receive additional federal funding to provide support to your child.

This form is not used to identify students' immigration status.

6. In what country was your child born? ___________________

7. Has your child ever received formal education outside of the United States? (Kindergarten ? 12th grade) ____Yes ____No

If yes: Number of months: ______________ Language of instruction: ______________

8. When did your child first attend a school in the United States?

(Kindergarten ? 12th grade)

_______________________

Month

Day Year

Thank you for providing the information needed on the Home Language Survey. Contact your school district if you have further questions about this form or about services available at your child's school.

Note to district: This form is available in multiple languages on . A response that includes a language other than English to question #2 OR question #3 triggers English language proficiency placement testing. Responses to questions #1 or #4 of a language other than English could prompt further conversation with the family to ensure that #2 and #3 were clearly understood. "Formal education" in #7 does not include refugee camps or other unaccredited educational programs for children.

Forms and Translated Material from the Bilingual Education Office of the Office of Superintendent of Public Instruction are licensed under a Creative Commons Attribution 4.0 International License.

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